Table 1.
Domains characterising struggling healthcare organisations
| Domain theme |
Definition representative quotes |
Supporting* studies, n=30 |
Contradicting* studies, n=30 |
| Poor organisational culture | ‘Norms, values and basic assumptions of a given organisation.’ | 30 (100%) | 14 (47%) |
| Limited involvement and ownership | 1. In contrast, ‘low’ performing organisations were generally characterised by confused and fragmented systems of accountability…senior managers only intervened in exceptional circumstances.46 | 27 (90%) | 8 (27%) |
| Not collaborative | 2. The lack of staff-to-staff connectivity translated into poor resident care. For example, one resident went without care during an 8-hour shift because the two (CNAs) assigned to that unit each thought the other was taking care of the resident.25 | 21 (70%) | 4 (13%) |
| Hierarchical | 3. ’Why is considered a bad word here. They don’t want to share the power. If you do, you get shot down. It’s that hierarchical thing.'25 | 17 (57%) | 4 (13%) |
| Disconnected leadership | 4. ’I would say minimal, minimal. They had some problems with the previous CEO. And after that there was an interim guy that I met just once.'41 | 16 (53%) | 2 (7%) |
| Inadequate infrastructure | Inadequate staffing (recruitment and retention) or resources, including poor technological or quality improvement infrastructure. | 27 (90%) | 18 (60%) |
| Minimal quality improvement systems | 5. Participants at low-performing hospitals described minimal or very recent use of formal problem-solving tools, such as root-cause analysis, and variable interest in data.24 | 20 (67%) | 10 (33%) |
| Insufficient staffing and high turnover | 6. (Struggling hospitals) had more turnover among nursing staff, more frequent use of per diem employees, and were more likely to have nurses (especially in the surgical intensive care unit) with less formal training.55 | 18 (60%) | 7 (23%) |
| Underdeveloped information technology | 7. Information technology systems were a common theme, viewed as a key to success across all hospitals, although successful implementation and support had only occurred in the high performers.41 | 17 (57%) | 6 (20%) |
| Lack of resources | 8. In contrast, lower-performing organisations struggled to have high-quality data reports. Participants described that they lacked the resources needed to collect timely and accurate data.37 | 15 (50%) | 4 (13%) |
| Lack of cohesive mission and vision | Mission is poorly defined, contrary to other stated missions, externally motivated or sets low expectations. | 21 (70%) | 5 (17%) |
| Conflicting missions | 9. The conflicting message regarding the organisational mission, that is, the explicit (resident care) versus the implicit (economic viability and regulatory compliance), fragmented and confused staff.25 | 12 (40%) | 1 (3%) |
| Externally motivated vision | 10. After Medicare readmissions penalties went into force, managers elevated the priority of readmissions reduction but without the emphasis on readmissions being detrimental to patients themselves.35 | 9 (30%) | 4 (13%) |
| Poorly defined goals | 11. Goal definition distinguished higher-performing hospitals…We found that aiming for general improvement seemed far less motivating than aiming for an absolute standard of zero (central line-associated blood stream infections).48 | 6 (20%) | 1 (3%) |
| Vision of mediocrity | 12. In the high-uptake practices, an aspirational uptake target was more likely to be reported than in the low-uptake practices.49 | 5 (17%) | 0 |
| System shocks | An organisation-wide event or change that detracts from day-to-day operations | 12 (40%) | 2 (7%) |
| C-suite (or senior leader) turnover | 13. ’Over the last 4 years…we’ve had four or five CEOs so it’s really been hard to figure out a pattern of leadership.'41 | 8 (27%) | 0 |
| Financial failure or severe difficulties | 14. Interviewees in another lower-performing practice pointed out difficulties in improving systems and achieving buy-in when a parent system absorbed the supplemental payments.38 | 4 (13%) | 0 |
| Mergers (or reorganisation) | 15. A mixture of two different organisational cultures, after merging…, was another issue that had a negative impact on the Trust. It was stated that there was inhouse fighting because one hospital’s staff thought they were better than the other…One interviewee likened the situation to the ’Berlin Wall'.46 | 4 (13%) | 0 |
| New EHR | 16. …only one of the higher-performing practices installed a new EHR in the midst of medical home implementation, whereas three of the five lower-performing practices did…38 | 4 (13%) | 2 (7%) |
| Major scandals | 17. In addition, there was poor public and press image…owing to the waiting list irregularities.46 | 1 (3%) | 0 |
| Dysfunctional external relations | Organisations had poor relationships with key stakeholders or governing bodies, or lacked well-functioning systems for collaboration with other healthcare facilities. | 7 (23%) | 2 (7%) |
| Limited collaboration | 18. Although low-performing hospitals mentioned collaboration with postacute providers, the relationships were described as less well-developed.35 | 5 (17%) | 2 (7%) |
| Antagonism with stakeholders | 19. Poorly performing Trusts were generally characterised by a history of poor relationships with other key stakeholders and organisations…46 | 4 (13%) | 0 |
| Strained relationship with governing body | 20. In contrast, relationships between the (local) level and higher zonal and regional levels were described as distant, with little contact between focal persons working at each of the administrative levels.37 | 2 (7%) | 0 |
*Studies may have evidence that both supported and contradicted themes.
Primary quotes from interviewees are shown in quotations. Abstracted summary quotes and interpretations by authors are shown without quotations.
CEO, chief executive officer; CNA, certified nursing assistant; EHR, electronic health record.